HPI: A 50 year old woman presents to the ER complaining of severe left-sided facial pain and swelling. The symptoms began 2 weeks prior with URI symptoms (fevers, runny nose, sinus congestion) and she was seen at another hospital and given augmentin, levofloxacin and dexamethasone with minimal improvement in symptoms. The pain and swelling have progressed in intensity and now she reports periorbital pain and blurry vision.
ROS: Positive for subjective fever, blurred vision (L>R eye), pain and redness of L eye, burning facial pain. Denies cough, chills, night sweats, weight loss, chest pain
PMH: HTN and DM2 (both diagnosed in the last month in the setting of recent illness)
PSH: no surgeries
Social: No recent travel or sick contacts. No tobacco or illicit drug use. Occasional alcohol use
Outpatient Rx: dexamethasone, levofloxacin, augmentin
PE: Temp 37.1C, HR 104 (regular), BP 114/52, SpO2 100% on RA
General: awake and alert, in no distress
HEENT: Left face with tender periorbital induration and edema extending to corner of mouth. Left proptosis and ptosis. Left pupil fixed and dilated with no extra-ocular motor function on left. Right eye normal in appearance. Right pupil reactive and EOM intact. Oral mucosa moist with left-sided pallor. Left posterior nare with small black eschar. No lymphadenopathy, thyroid not enlarged, no carotid bruits.
Neuro: Absent fine/gross touch sensation over V1 and V2 distribution on left face. Left eye without response to light or threat. Right eye 20/20. No extraocular movements of left eye, normal EOM on right.
Contrast enhanced MRI brain obtained in the ER is shown below (with positive arrow signs!)
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